Cirrhosis and complications

Quick Overview

Cirrhosis represents end-stage liver disease with irreversible fibrosis, leading to portal hypertension and hepatic dysfunction. Management focuses on surveillance for complications (variceal bleeding, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy), risk stratification using Child-Pugh and MELD scores, and timely transplant referral. NICE NG50 emphasizes structured surveillance and evidence-based interventions.

Core Facts & Concepts

Child-Pugh Score (each parameter scored 1-3):

• Bilirubin (<34 / 34-50 / >50 µmol/L)
• Albumin (>35 / 28-35 / <28 g/L)
• INR (<1.7 / 1.7-2.3 / >2.3)
• Ascites (none / mild / moderate-severe)
• Encephalopathy (none / grade 1-2 / grade 3-4)
• Class A: 5-6 points (1-year survival 100%), Class B: 7-9 (80%), Class C: 10-15 (45%)

MELD Score = 3.78×ln[bilirubin(mg/dL)] + 11.2×ln[INR] + 9.57×ln[creatinine(mg/dL)] + 6.43

• ≥15: Consider transplant referral
• ≥40: 71% 3-month mortality

📊 Key Thresholds:

• Varices screening: OGD at diagnosis, repeat every 2-3 years if none found
• SBP prophylaxis: Ascitic protein <15 g/L + Child-Pugh ≥9 or renal impairment
• Diuretic ratio: Spironolactone 100mg : Furosemide 40mg (maintain K⁺)

Problem-Solving Approach

Managing Ascites (stepwise):

1. Dietary sodium restriction (<90 mmol/day = 5g salt)
2. Diuretics: Start spironolactone 100mg + furosemide 40mg; increase weekly to max 400mg:160mg
3. Monitor: Weight loss target 0.5kg/day (no peripheral oedema) or 1kg/day (with oedema)
4. Refractory ascites (10%): Large-volume paracentesis (LVP) + 8g albumin per litre removed if >5L
5. Consider TIPS if recurrent LVP required


🚩 Spontaneous Bacterial Peritonitis (SBP):

• Suspect if: fever, abdominal pain, encephalopathy, AKI, or unexplained deterioration
• Diagnostic tap: Neutrophils >250 cells/mm³ = SBP
• Immediate treatment: IV cefotaxime 2g BD or tazocin 4.5g TDS × 5 days
• Give IV albumin 1.5g/kg at diagnosis, then 1g/kg on day 3 (prevents hepatorenal syndrome)
• Secondary prophylaxis: Ciprofloxacin 500mg OD lifelong

Hepatic Encephalopathy:

1. Exclude precipitants: infection, GI bleed, constipation, drugs, electrolyte disturbance
2. Lactulose 15-30ml TDS (target 2-3 soft stools/day)
3. Add rifaximin 550mg BD if recurrent episodes

Analysis Framework

Transplant Referral Criteria:

• MELD ≥15 OR
• Refractory ascites OR
• Recurrent variceal bleeding OR
• HCC within Milan criteria OR
• Hepatopulmonary syndrome

Visual Aid

Key Points Summary

✓ Child-Pugh and MELD scores predict mortality; MELD ≥15 triggers transplant assessment

✓ Variceal screening: OGD at diagnosis; band ligation for medium/large varices or propranolol 80mg BD

✓ Ascites management: Salt restriction + spironolactone 100mg:furosemide 40mg ratio; LVP + albumin if refractory

✓ SBP diagnosis: Ascitic neutrophils >250/mm³; treat with cefotaxime 2g BD + albumin 1.5g/kg then 1g/kg day 3

✓ SBP prophylaxis: Ciprofloxacin 500mg OD if ascitic protein <15g/L + Child-Pugh ≥9

✓ Hepatic encephalopathy: Exclude precipitants; lactulose 15-30ml TDS (2-3 stools/day) ± rifaximin 550mg BD

✓ HCC surveillance: 6-monthly USS + AFP in all cirrhotic patients; early detection improves transplant eligibility